MARION COUNTY HEALTH DEPARTMENT
Fraud and Abuse Referral Form
       

The purpose of this form is to document or report any suspected fraud or abuse. If you suspect any fraud or abuse please report the activity (anonymously if preferred) by:
 
Calling the MCHD Compliance Hotline: 1-877-706-4445 or
Faxing the completed form to: (503) 364-6552 or
E-Mail completed form to: reporthealthfraud@co.marion.or.us
Completing and submitting the form online: www.co.marion.or.us/HLT
Mailing the completed form to: Marion County Health Department
Attn: FACC
3180 Center St NE
Salem, OR 97301
 

We cannot release information about the status of or findings from an investigation of suspected Fraud or Abuse. Information collected during our investigation may be shared with the Oregon Department of Human Services and other government agencies as allowed by law.

What is Fraud? An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person.

What is Abuse? Practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to Medicaid, Medicare or the MVBCN, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.
SECTION 1: I wish to remain (choose one):
  Anonymous
(clears contact information)		 Confidential No Restriction
       
  How may we contact you? (Do not complete if you wish to remain anonymous.)
     
  Name:
  Address:
  City / State / Zip
  Phone:
  E-mail:
  Medicaid / Medicare Provider ID (if applicable):
       
SECTION 2: Suspected Fraud and Abuse Complaint
       
1. Name(s) of the individual(s) suspected of fraud or abuse:
       
2. Department/Service Area(s) involved in the suspected fraud or abuse:
       
3. Description of suspected fraud or abuse in as much detail as possible. Include such things as the date alleged activity occurred, whether or not you believe the alleged behavior is still occurring, if you notified a supervisor or any other personnel, law enforcement or outside agency about this allegation:
       
4. What type of documentation are you able to provide in support of this report of fraud and abuse? (Examples: copies, photos, schedules, etc.)
       
5. Names of witnesses or others who may have knowledge of this allegation (Please include contact information if possible):
       
6. How did you become aware of the incident(s)? (Examples: witnessed firsthand, heard it from another person, etc.)
       
7. Are you willing to be interviewed regarding these allegations?
  Yes No  
       
8. Today's Date:    
       
9. Additional comments